Project Summary: This project will assess the impact of a pediatric tele-simulation program in the Critical Access Hospital Emergency Department setting on the safety of the emergency care provided to children treated at these rural safety net institutions. The Critical Access Hospital (CAH) system was created to serve as a healthcare safety net for rural America. These 25 or fewer bed hospitals provide 24/7 emergency care for patients living in their catchment areas. Many of these hospitals do not have access to pediatricians or to physicians with significant pediatric training. Medical simulation has been shown to improve team performance, acquisition of skills and knowledge, and provider comfort level. Our prior work demonstrated that a pediatric simulation program is feasible and sustainable in the CAH Emergency Department (ED) setting. Recently we found that this program can be run effectively via ?tele-simulation?, and that program participation improves ED provider comfort with pediatric patients, performance skills, and team functioning during simulated resuscitations. However, the impact on patient safety of these improved skills is unknown. Hypothesis: A novel, longitudinal, in-situ pediatric tele-simulation program will improve the safety of emergency care delivered to rural children in the Critical Access Hospital Emergency Department setting. Previously identified pediatric emergency care safety metrics will be abstracted from the electronic medical records of all patients < 18 years old seen in the four participating EDs throughout the three year study period. Monthly, over the second year of the study period, standardized pediatric scenarios will be run via tele- simulation in three CAH EDs, expanding our previously proven methodology. The additional CAH will serve as a control hospital. Team performance will be documented using a validated checklist. Safety of care over time will be assessed via longitudinal changes in pediatric emergency care safety metrics. Changes in simulation performance and high acuity patient care performance over time will be assessed and compared with changes in patient safety metrics. Children in rural areas have restricted choices for local emergency care. Many are seen in resource- limited settings where concerns have been raised about pediatric care. CAHs are a medical safety net for rural patients, yet safety issues have been raised regarding these institutions. We propose a unique pilot project designed both to assess the safety of pediatric emergency care provided in the CAH setting and to employ a tele-simulation program aimed at improving that care. We will do this using a set of rigorously developed, not yet widely implemented, safety metrics. Demonstrated success of this intervention will provide a crucial framework for the widespread implementation of tele- simulation programs designed to improve the emergency care available to rural children.